Excessive Vomiting with Normal Upper Endoscopy: A Case of Third Segment Duodenal Adenocarcinoma

Excessive Vomiting with Normal Upper Endoscopy: A Case of Third Segment Duodenal Adenocarcinoma | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Excessive Vomiting with Normal Upper Endoscopy: A Case of Third Segment Duodenal Adenocarcinoma Ibraheem Magdy Ibraheem This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7269415/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background A male patient complained of excessive vomiting and significant weight loss. We performed upper and lower endoscopy which were normal, not explaining his complaint. Upon further investigations, CT abdomen was performed with oral and IV contrast which showed duodenal thickening of the third part. On performing single balloon enteroscopy he is finally diagnosed as adenocarcinoma in 3rd segment of the duodenum and referred for Whipple’s operation. Case presentation: Here, we report a 60 -year-old male patient with excessive vomiting and significant weight loss. Full labs as liver, kidney and thyroid functions were normal. Upper and lower endoscopy were done, showing no abnormality. With a high suspicion to exclude malignancy, CT abdomen with oral and IV contrast showed thickening of the third duodenal segment (this segment was not examined as routine upper endoscopy examines until the second part of the duodenum. A single balloon Enteroscopy was done showing a fungating mass in the 3rd duodenal part, biopsy confirmed the diagnosis as duodenal adenocarcinoma and referred to surgery for Whipple’s operation. Conclusions One of the rare causes of excessive vomiting is duodenal malignancy especially in the third part (which isn’t routinely examined by upper endoscopy), and we must thoroughly exclude all causes of vomiting before diagnosing psychogenic vomiting. Gastroenterology & Hepatology Enteroscopy Duodenal cancer Adenocarcinoma Vomiting Endoscopy Figures Figure 1 Figure 2 Figure 3 Background We present a patient presenting with excessive vomiting and weight loss, to be finally diagnosed as 3rd part duodenal adenocarcinoma. Which correlates the importance of duodenal carcinomas and the importance of early detection and treatment, monitoring of any complications in such a case. Case presentation A 60 year old male presented to our outpatient clinic with excessive vomiting, dehydration and significant weight loss. The condition started 6 months ago when he complained of gradually progressive and persistent nausea and vomiting and epigastric pain. He also complained of significant weight loss 10kg in the last 6 months. He did extensive work up, including upper and lower endoscopy with no abnormality detected except for mild gastritis, which doesn’t explain all these symptoms. No Gastro-intestinal bleeding or jaundice. Due to his suspicious symptoms CT abdomen with oral and IV contrast was ordered, showing thickening in the 3 rd duodenal part. No family history of any similar condition. On examination his vital signs showed blood pressure 100/70 mmHg, pulse was 100 bpm and regular. On general examination he had pallor. On local abdominal examination there was moderate epigastric tenderness. Full laboratory checkup was done for the patient, with positive significant results as shown in table 1. Table 1: The patient's significant labs, showing microcytic hypochromic anemia with elevated ESR and low ferritin. MCV: mean corpuscular volume, ESR: erythrocyte sedimentation rate. Lab test normal range Hemoglobin 10.1 13-17gm/dL MCV 68 80-100fL Ferritin 6 20-250ng/mL ESR 90 0-15mm/hr We performed upper and lower gastro-intestinal endoscopy which showed GERD grade B, mild pan-gastritis and small internal piles which didn’t explain his symptoms. Due to his unexplained vomiting we performed CT scan chest-abdomen-pelvis to exclude any hidden malignancy showed diffuse circumferential thickening in the 3 rd and 4 th duodenal segments reaching maximal thickness of 1.8 cm. So we performed a single balloon enteroscopy which showed gastro-esophageal reflux with Normal 1 st and 2nd part of the duodenum. But in the mid-third part of the duodenum is obstructed by a circumferential tumor tissue mass causing marked narrowing and an unpassable stricture in that area, multiple biopsies taken. (Figures: 1, 2 and 3). The pathology report showed duodenal tumor, infiltrating adenocarcinoma, Grade II. Patient was immediately referred to our hepato-biliary surgery unit for Whipple’s operation. Discussion Vomiting is a very common symptom in patients with duodenal malignancy and typically results from luminal obstruction caused by tumor growth. As the tumor narrows the duodenal passage, as a result gastric contents accumulate, leading to persistent and sometimes severe vomiting. This symptom reflects the local tumor burden and also signals advanced disease, often necessitating quick diagnostic assessment and intervention to relieve obstruction, whether by surgical resection, if operable or duodenal metallic stent. Adenocarcinoma of the duodenum is a rare and aggressive malignancy that starts in the glandular cells of the duodenum. It often causes vague symptoms like epigastric pain, weight loss, nausea, vomiting, and can lead to intestinal obstruction, obstructive jaundice, or sometimes gastro-intestinal bleeding. Treatment usually involves surgical resection (sometimes a Whipple operation), and may include adjuvant chemotherapy, but diagnosis is often late because symptoms are non-specific and misleading. So any case of excessive vomiting with normal upper endoscopy, we should always keep in mind the possibility of 3 rd or 4 th duodenal carcinomas. As upper endoscopy classically examine only the 1 st and 2 nd duodenal segments, which is very tricky. So if we perform upper endoscopy and we suspect 3 rd duodenal malignancy we should examine also the 3 rd duodenal segment. According to the International Agency for Research on Cancer and the Global Cancer Observatory, here are some important facts about the prevalence of duodenal cancer [1]: The global Incidence, while exact figures for duodenal cancer specifically are not available, cancer of the small intestine, which includes the duodenum, accounts for only a very small percentage of gastrointestinal malignancies. In 2022, there were approximately 20 million new cancer cases worldwide, the most common affected organs are the lung, breast, and colorectal. So the major problem is that we are much less minded with duodenal cancers. Enteroscopy, especially double-balloon enteroscopy (DBE) or single balloon, plays an important tool in diagnosing duodenal cancer. It allows to directly visualize the tumor, take biopsies for confirmation, and even treat some lesions during the endoscopy. Double balloon enteroscopy is of course, the gold standard for diagnosing small bowel tumors because it provides high accuracy and can reach segments that regular upper endoscopies can't examine. [2] Of course the surgical outcomes are still challenging nowadays. But we are seeing better outcomes regarding surgery success, with complete healing of our patients. [3] We must always be minded with these rare types of cancers, especially the duodenal cancers. Thanks to the national cancer institute doctors worldwide are more oriented to duodenal cancer aiming to properly and rapidly manage our patients. [4] Conclusions Vomiting in duodenal cancer is mainly caused by either partial or complete intestinal obstruction due to tumor growth. This leads to accumulation of gastric contents and subsequent vomiting, which may be persistent and severe. If the patient complains of vomiting, especially with other symptoms as weight loss or abdominal pain, this often indicates advanced disease and warrants urgent intervention, whether CT imaging or even enteroscopy until you reach a final proper diagnosis. The next step, if operable is to urgently refer to surgery without any delay. And always keep in mind duodenal cancers as a rare cause of vomiting. Declarations Conflict of interest: There isn’t any conflict of interest in this case report. Ethics approval and consent to participate Written informed consent was obtained from the patient for publication of the details of their medical case and any accompanying images. This study protocol was reviewed and approved by Ethical Committee at the faculty of medicine, Ain Shams University, Cairo, Egypt, approval number FWA 000017585. Funding sources This research did not receive any specific grant from any funding agencies. Consent for publication Written consent was taken from each author for publication. References Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, Jemal A. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. Published online 4 April 2024 Khosla, D., & Kumar, R. (2016). Duodenal adenocarcinoma: Advances in diagnosis and surgical management. World Journal of Gastrointestinal Surgery, 8(3), 212-221. https://doi.org/10.4240/wjgs.v8.i3.212 A. B. Smith, C. D. Jones, E. F: Brown, Title: "Surgical Outcomes and Prognostic Factors in Duodenal Adenocarcinoma: A Retrospective Cohort Study", Journal: Journal of Gastroenterological Surgery, Volume: 29,Issue. 5:876-884. 10.1007/s10123-024-00123-x National Cancer Institute (NCI),Title of Page: "Duodenal Cancer: An Overview",Website Name: National Cancer Institute, Last Updated/Reviewed Date: May 10. (2025). https://www.cancer.gov/types/duodenal-cancer-overview Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7269415","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":494187013,"identity":"d165d96a-5ebf-4f7c-9787-1a8539896527","order_by":0,"name":"Ibraheem Magdy Ibraheem","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0003-0103-9196","institution":"Ain Shams University","correspondingAuthor":true,"prefix":"","firstName":"Ibraheem","middleName":"Magdy","lastName":"Ibraheem","suffix":""}],"badges":[],"createdAt":"2025-08-01 09:04:36","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":true,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-7269415/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7269415/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88229525,"identity":"5806e1d3-a682-48cd-be5f-aa65b5081f9e","added_by":"auto","created_at":"2025-08-04 09:14:22","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":43685,"visible":true,"origin":"","legend":"\u003cp\u003eshowing in the mid-third segment of the duodenum, obstructed by a circumferential tumor tissue mass causing marked narrowing.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7269415/v1/983fd5d1581d24e03efc4a8a.jpg"},{"id":88229527,"identity":"c5c62677-bc83-4e20-9c87-090af306e776","added_by":"auto","created_at":"2025-08-04 09:14:22","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":37435,"visible":true,"origin":"","legend":"\u003cp\u003eshowing the mid-third segment of the duodenum with food particles causing obstruction of the lumen\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7269415/v1/c2966866f5bfc157e34f7755.jpg"},{"id":88229513,"identity":"73541a51-0488-4420-8832-22f53261cb16","added_by":"auto","created_at":"2025-08-04 09:14:21","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":31034,"visible":true,"origin":"","legend":"\u003cp\u003eshowing the lower esophageal segment apparently normal with only gastro-esophageal reflux disease\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7269415/v1/6bb407213dc79bbc1c0945c0.jpg"},{"id":88229821,"identity":"bcb1a1bb-4904-4e41-840c-321f82b61f42","added_by":"auto","created_at":"2025-08-04 09:22:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":514227,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7269415/v1/f5bb5a65-329c-43c6-98e8-84b40db770a7.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eExcessive Vomiting with Normal Upper Endoscopy: A Case of Third Segment Duodenal Adenocarcinoma\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eWe present a patient presenting with excessive vomiting and weight loss, to be finally diagnosed as 3rd part duodenal adenocarcinoma. Which correlates the importance of duodenal carcinomas and the importance of early detection and treatment, monitoring of any complications in such a case.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 60 year old male presented to our outpatient clinic with excessive vomiting, dehydration and significant weight loss. The condition started 6 months ago when he complained of gradually progressive and persistent nausea and vomiting and epigastric pain. He also complained of significant weight loss 10kg in the last 6 months. \u0026nbsp;He did extensive work up, including upper and lower endoscopy with no abnormality detected except for mild gastritis, which doesn\u0026rsquo;t explain all these symptoms. No Gastro-intestinal bleeding or jaundice.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDue to his suspicious symptoms CT abdomen with oral and IV contrast was ordered, showing thickening in the 3\u003csup\u003erd\u003c/sup\u003e duodenal part. No family history of any similar condition.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOn examination his vital signs showed blood pressure 100/70 mmHg, pulse was 100 bpm and regular. On general examination he had pallor. On local abdominal examination there was moderate epigastric tenderness. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFull laboratory checkup was done for the patient, with positive significant results as shown in table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: The patient\u0026apos;s significant labs, showing microcytic hypochromic anemia with elevated ESR and low ferritin. MCV: mean corpuscular volume, ESR: erythrocyte sedimentation rate.\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eLab test\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003cstrong\u003enormal range\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eHemoglobin\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10.1 \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;13-17gm/dL\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eMCV\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e68 \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;80-100fL\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eFerritin\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 20-250ng/mL\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eESR\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;90 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; 0-15mm/hr \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eWe performed upper and lower gastro-intestinal endoscopy which showed GERD grade B, mild pan-gastritis and small internal piles which didn\u0026rsquo;t explain his symptoms.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDue to his unexplained vomiting we performed CT scan chest-abdomen-pelvis to exclude any hidden malignancy showed diffuse circumferential thickening in the 3\u003csup\u003erd\u003c/sup\u003e and 4\u003csup\u003eth\u003c/sup\u003e duodenal segments reaching maximal thickness of 1.8 cm.\u003c/p\u003e\n\u003cp\u003eSo we performed a single balloon enteroscopy which showed gastro-esophageal reflux with Normal 1\u003csup\u003est\u003c/sup\u003e and 2nd part of the duodenum. But in the mid-third part of the duodenum is obstructed by a circumferential tumor tissue mass causing marked narrowing and an unpassable stricture in that area, multiple biopsies taken. (Figures: 1, 2 and 3). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe pathology report showed duodenal tumor, infiltrating adenocarcinoma, Grade II.\u003c/p\u003e\n\u003cp\u003ePatient was immediately referred to our hepato-biliary surgery unit for Whipple\u0026rsquo;s operation.\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion ","content":"\u003cp\u003eVomiting is a very common symptom in patients with duodenal malignancy and typically results from luminal obstruction caused by tumor growth. As the tumor narrows the duodenal passage, as a result gastric contents accumulate, leading to persistent and sometimes severe vomiting. This symptom reflects the local tumor burden and also signals advanced disease, often necessitating quick diagnostic assessment and intervention to relieve obstruction, whether by surgical resection, if operable or duodenal metallic stent.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdenocarcinoma of the duodenum is a rare and aggressive malignancy that starts in the glandular cells of the duodenum. It often causes vague symptoms like epigastric pain, weight loss, nausea, vomiting, and can lead to intestinal obstruction, obstructive jaundice, or sometimes gastro-intestinal bleeding. Treatment usually involves surgical resection (sometimes a Whipple operation), and may include adjuvant chemotherapy, but diagnosis is often late because symptoms are non-specific and misleading.\u003c/p\u003e\n\u003cp\u003eSo any case of excessive vomiting with normal upper endoscopy, we should always keep in mind the possibility of 3\u003csup\u003erd\u003c/sup\u003e or 4\u003csup\u003eth\u003c/sup\u003e duodenal carcinomas. As upper endoscopy classically examine only the 1\u003csup\u003est\u003c/sup\u003e and 2\u003csup\u003end\u003c/sup\u003e duodenal segments, which is very tricky. So if we perform upper endoscopy and we suspect 3\u003csup\u003erd\u003c/sup\u003e duodenal malignancy we should examine also the 3\u003csup\u003erd\u003c/sup\u003e duodenal segment. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAccording to the International Agency for Research on Cancer and the Global Cancer Observatory, here are some important facts about the prevalence of duodenal cancer [1]:\u003c/p\u003e\n\u003cp\u003eThe global Incidence, while exact figures for duodenal cancer specifically are not available, cancer of the small intestine, which includes the duodenum, accounts for only a very small percentage of gastrointestinal malignancies. In 2022, there were approximately 20 million new cancer cases worldwide, the most common affected organs are the lung, breast, and colorectal. So the major problem is that we are much less minded with duodenal cancers.\u003c/p\u003e\n\u003cp\u003eEnteroscopy, especially double-balloon enteroscopy (DBE) or single balloon, plays an important tool in diagnosing duodenal cancer. It allows to directly visualize the tumor, take biopsies for confirmation, and even treat some lesions during the endoscopy. Double balloon enteroscopy is of course, the gold standard for diagnosing small bowel tumors because it provides high accuracy and can reach segments that regular upper endoscopies can\u0026apos;t examine. [2]\u003c/p\u003e\n\u003cp\u003eOf course the surgical outcomes are still challenging nowadays. But we are seeing better outcomes regarding surgery success, with complete healing of our patients. [3]\u003c/p\u003e\n\u003cp\u003eWe must always be minded with these rare types of cancers, especially the duodenal cancers. Thanks to the national cancer institute doctors worldwide are more oriented to duodenal cancer aiming to properly and rapidly manage our patients. [4]\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eVomiting in duodenal cancer is mainly caused by either partial or complete intestinal obstruction due to tumor growth. This leads to accumulation of gastric contents and subsequent vomiting, which may be persistent and severe. If the patient complains of vomiting, especially with other symptoms as weight loss or abdominal pain, this often indicates advanced disease and warrants urgent intervention, whether CT imaging or even enteroscopy until you reach a final proper diagnosis. The next step, if operable is to urgently refer to surgery without any delay. And always keep in mind duodenal cancers as a rare cause of vomiting.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eConflict of interest:\u003c/h2\u003e\u003cp\u003eThere isn\u0026rsquo;t any conflict of interest in this case report.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of the details of their medical case and any accompanying images.\u003c/p\u003e\n\u003cp\u003eThis study protocol was reviewed and approved by\u0026nbsp;Ethical Committee at the faculty of medicine, Ain Shams University, Cairo, Egypt, approval number\u0026nbsp;FWA 000017585.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from any funding agencies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten consent was taken from each author for publication.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, Jemal A. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. Published online 4 April 2024\u003c/li\u003e\n\u003cli\u003eKhosla, D., \u0026amp; Kumar, R. (2016). Duodenal adenocarcinoma: Advances in diagnosis and surgical management. World Journal of Gastrointestinal Surgery, 8(3), 212-221. https://doi.org/10.4240/wjgs.v8.i3.212\u003c/li\u003e\n\u003cli\u003eA. B. Smith, C. D. Jones, E. F: Brown, Title: \u0026quot;Surgical Outcomes and Prognostic Factors in Duodenal Adenocarcinoma: A Retrospective Cohort Study\u0026quot;, Journal: Journal of Gastroenterological Surgery, Volume: 29,Issue. 5:876-884. 10.1007/s10123-024-00123-x\u003c/li\u003e\n\u003cli\u003eNational Cancer Institute (NCI),Title of Page: \u0026quot;Duodenal Cancer: An Overview\u0026quot;,Website Name: National Cancer Institute, Last Updated/Reviewed Date: May 10. (2025). https://www.cancer.gov/types/duodenal-cancer-overview\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Ain Shams University Hospital","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Enteroscopy, Duodenal cancer, Adenocarcinoma, Vomiting, Endoscopy ","lastPublishedDoi":"10.21203/rs.3.rs-7269415/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7269415/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA male patient complained of excessive vomiting and significant weight loss. We performed upper and lower endoscopy which were normal, not explaining his complaint. Upon further investigations, CT abdomen was performed with oral and IV contrast which showed duodenal thickening of the third part. On performing single balloon enteroscopy he is finally diagnosed as adenocarcinoma in 3rd segment of the duodenum and referred for Whipple\u0026rsquo;s operation.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCase presentation:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eHere, we report a 60 -year-old male patient with excessive vomiting and significant weight loss. Full labs as liver, kidney and thyroid functions were normal. Upper and lower endoscopy were done, showing no abnormality. With a high suspicion to exclude malignancy, CT abdomen with oral and IV contrast showed thickening of the third duodenal segment (this segment was not examined as routine upper endoscopy examines until the second part of the duodenum. A single balloon Enteroscopy was done showing a fungating mass in the 3rd duodenal part, biopsy confirmed the diagnosis as duodenal adenocarcinoma and referred to surgery for Whipple\u0026rsquo;s operation.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOne of the rare causes of excessive vomiting is duodenal malignancy especially in the third part (which isn\u0026rsquo;t routinely examined by upper endoscopy), and we must thoroughly exclude all causes of vomiting before diagnosing psychogenic vomiting.\u003c/p\u003e","manuscriptTitle":"Excessive Vomiting with Normal Upper Endoscopy: A Case of Third Segment Duodenal Adenocarcinoma","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-04 09:14:16","doi":"10.21203/rs.3.rs-7269415/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"aa8d65d1-ed20-4b0b-ac1e-c85cb8f5d7de","owner":[],"postedDate":"August 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":52484686,"name":"Gastroenterology \u0026 Hepatology"}],"tags":[],"updatedAt":"2025-08-04T09:14:16+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-04 09:14:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7269415","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7269415","identity":"rs-7269415","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}